Significant Clarifications for Outpatient E/M

The AMA issued a recent CPT update which contained important guidance regarding what may and may not be considered in determining the level of medical decision making. 

The clarification states, “The ordering and actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the levels of E/M services when the professional interpretation of those tests/studies is reported separately by the physician or other qualified health care professional reporting the E/M service.  Tests that do not require separate interpretation (eg, tests that are results only) and are analyzed as part of MDM do not count as an independent interpretation, but may be counted as ordered or reviewed for selecting an MDM level.” 

The AMA also added a new definition regarding analysis of diagnostic tests as follows, Analyzed: the process of using the data as part of the MDM.  The data element itself may not be subject to analysis (eg, glucose), but is instead included in the thought processes for diagnostic evaluation, or treatment.  Tests ordered are presumed to be analyzed when the results are reported.  Therefore, when they are ordered during an encounter, they are counted in that encounter.  Tests that are ordered outside of an encounter may be counted in the encounter in which they are analyzed. In the case of a recurring order, each new result may be counted in the encounter in which it is analyzed.  For example, an encounter that includes an order for monthly prothrombin times would count for one prothrombin time ordered and reviewed.  Additional future results, if analyzed in a subsequent encounter, may be counted as a single test in that subsequent encounter.  Any service for which the professional component is separately reported by the physician or other qualified health care professional reporting the E/M service is not counted as a data element ordered, reviewed, analyzed, or independently interpreted for the purposes of determining the level of MDM.”

This clarification was made in the AMA Errata released on March 9th  for Evaluation and Management Guidelines for office/outpatient services (99202-99215) that went into effect on January 1, 2021. 

This clarification is SIGNIFICANT and will impact all E/M coding. In the past, you could not consider independent visualization as part of the MDM if you were also billing for the interpretation.  For example, you could not count independent visualization of radiology images as part of the MDM if you were also going to separately bill the radiology interpretation but you could count the ordering of those tests.  However, the AMA has now clarified that it is not permissible to count the ordering or review of diagnostic tests if you (or the group) are also going to bill for the professional component of the diagnostic test.  As a reminder, the AMA specifically excluded tests that are considered “results only” from this rule.

This change will likely have a negative impact on the overall level of service for providers due to the limited ability to count the ordering of unique tests in Category 1 – “Amount and/or Complexity of Data to be Reviewed and Analyzed”.

We strongly recommend you revise your E/M policies and procedures to facilitate compliance with this clarification.  We also recommend immediate training to clinical and coding staff regarding the clarification.  Additionally, we recommend routine monitoring and auditing of outpatient E/M services.  

The AMA revised guidelines are located at:

Most of the Medicare Administrative Contractors (MACs) have updated their E/M FAQ pages consistent with the AMA clarification. HBE’s team of coding and compliance experts is available to assist you with external reviews of your documentation, coding and reimbursement as well as providing customized education and training for your staff.  We are also available to provide assistance with conducting risk assessments, internal investigations and policy and procedure development.  

DISCLAIMER:  This newsletter contains only summary information and highlights; it should be read in conjunction with the full article or document provided as a link.  Any advice or recommendations are general and specific questions should be directed to professional counsel.

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